Severe Pre-eclampsia Case Discussion

Scenario: Patient presented with new onset elevated blood pressure in her 34 weeks of gestation. On thorough history; patient is having headaches, visual disturbances, and abdominal pain. Urine analysis showed proteinuria

 

» Clinical features of severe pre-eclampsia?

  • Headache (most commonly the posterior part of the head is hypo perfused -> occipital headache)
  • Visual changes (flashing lights, blurred vision, blindness)
  • Mid epigastric pain (due to swelling of Glisson’s capsule of the liver)
  • Signs: pulmonary edema, oliguria, cyanosis

 

» Risk factors?

  • Nulliparity
  • Age >40, or <18
  • High BMI
  • Prev pre-eclampsia
  • FHx
  • HTN, DM, GDM
  • Vascular\connective tissue ds
  • Thrombotic ds (antiphospholipid, thrombophilia)

 

» What tests to order?

  • Labs:
    • CBC
    • Coagulation profile and platelet count (DIC, HELLP)
    • Peripheral smear (?): hemolysis (HELLP)
    • Liver enzymes: ALT\AST (HELLP)
    • Serum creatinine + uric acid
    • 24-hr urine collection for protein and Cr (or urine dipstick)
  • Head CT, only if:
    • Sudden severe headache
    • Focal neurological deficits or altered mental status
    • Seizures w\ prolonged postictal state
    • Atypical presentation of pre-eclampsia
  • Fetal wellbeing:
    • US, doppler, CTG monitoring, BPP

 

» Diagnostic criteria of severe pre-eclampsia? (>20 wks of gestation)

  1. BP >160\110 (on 2 occasions + at least 6 hrs apart)
  2. Proteinuria (>5 grams in a 24-hr collection)
  3. Symptoms of severe features

 

» Management of severe pre-eclampsia?

  1. Stabilize the pt (ABCs)
  2. Admit to a specialist unit

If < 34 wks:

  • Dexamethasone (4 doses of 6 mg every 12 hrs): to accelerate fetal lung maturity
  • MgSo4 (4 g IV over 20 mins -> constant IV infusion -> continued 24 hrs post-partum)
  • If signs of toxicity (↓ BP, HR, UO, reflexes, respiratory depression) -> give IV calcium gluconate
  • Lower BP -> IV hydrazine or labetalol (aim for DBP of 90-100)
  • Monitor for complications:
    • Eclampsia (seizures) -> give IV benzodiazepines
    • Vaginal bleeding (abruptio placenta)
    • Oliguria (renal insufficiency)
    • Fetal well-being
  • If mother or fetus are uneatable -> deliver!

 

If > 34 wks:

  • Give MgSo4 and continue 24-hrs post-partum
  • Deliver:
    • If mom and fetus stable -> induce labor with IV oxytocin and amniotomy
    • If mom or fetus unstable -> C section

 


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